Derivation and Internal Validation of a Disease-Specific Cardiovascular Risk Prediction Model for Patients With Psoriatic Arthritis and Psoriasis

OBJECTIVE

To address suboptimal cardiovascular risk prediction in patients with psoriatic disease (PsD), we developed and internally validated a five-year disease-specific cardiovascular risk prediction model.

METHODS

We analyzed data from a prospective cohort of participants with PsD without a history of cardiovascular events. Traditional cardiovascular risk factors and PsD-related measures of disease activity were considered as potential predictors. The study outcome included nonfatal and fatal cardiovascular events. A base prediction model included 10 traditional cardiovascular risk factors. Eight PsD-related factors were assessed by adding them to the base model to create expanded models, which were controlled for PsD therapies. Variable selection was performed using Least Absolute Shrinkage and Selection Operator (LASSO) penalized regression with 10-fold cross-validation. Model performance was assessed using measures of discrimination and calibration and measures of sensitivity and specificity.

RESULTS

Between 1992 and 2020, 85 of 1,336 participants developed cardiovascular events. Discrimination of the base model (with traditional cardiovascular risk factors alone) was excellent, with an area under the receiver operator characteristic curve (AUC) of 85.5 (95% confidence interval [CI] 81.9-89.1). Optimal models did not select any of the tested disease-specific factors. In a sensitivity analysis, which excluded lipid lowering and antihypertensive treatments, the number of damaged joints was selected in the expanded model. However, this model did not improve risk discrimination compared to the base model (AUC 85.5, 95% CI 82.0-89.1).

CONCLUSION

Traditional cardiovascular risk factors alone are effective in predicting cardiovascular risk in patients with PsD. A risk score based on these factors performed well, indicating excellent discrimination and calibration.

Characterizing Hypertension Specialist Care in Canada: A National Survey

Background

The hypertension specialist often receives referrals of patients with young-onset, severe, difficult-to-control hypertension, patients with hypertensive emergencies, and patients with secondary causes of hypertension. Specialist hypertension care compliments primary care for these complex patients and contributes to an overall hypertension control strategy. The objective of this study was to characterize hypertension centres and the practice patterns of Canadian hypertension specialists.

Methods

Adult hypertension specialists across Canada were surveyed to describe hypertension centres and specialist practice in Canada, including the following: the patient population managed by hypertension specialists; details on how care is provided; practice pattern variations; and differences in access to specialized hypertension resources across the country.

Results

The survey response rate was 73.5% from 25 hypertension centres. Most respondents were nephrologists and general internal medicine specialists. Hypertension centres saw between 50 and 2500 patients yearly. A mean of 17% (± 15%) of patients were referred from the emergency department and a mean of 52% (± 24%) were referred from primary care. Most centres had access to specialized testing (adrenal vein sampling, level 1 sleep studies, autonomic testing) and advanced therapies for resistant hypertension (renal denervation). Considerable heterogeneity was present in the target blood pressure in young people with low cardiovascular risk and in the diagnostic algorithms for investigating secondary causes of hypertension.

Conclusions

These results summarize the current state of hypertension specialist care and highlight opportunities for further collaboration among hypertension specialists, including standardization of the approach to specialist care for patients with hypertension.

Cardiac Magnetic Resonance Imaging and Clinical Follow-up in Antimalarial-induced Cardiomyopathy in Patients With Systemic Lupus Erythematosus

Antimalarial-induced cardiomyopathy is under-recognized in clinical practice and there is limited data on the evolution of cardiac imaging abnormalities after cessation of anti-malarial therapy. In this case series of 9 patients with antimalarial-induced cardiomyopathy, follow-up cardiac magnetic resonance imaging demonstrated interval increase in late gadolinium enhancement extent in 89% of patients and interval decrease in left ventricular ejection fraction in all, despite cessation of anti-malarial therapy. Progression of cardiac abnormalities despite cessation of therapy underscores the important role of imaging in the early recognition of antimalarial-related treatment changes.

Examining the Role of Physical Activity Interventions in Modulating Androgens and Cardiovascular Health in Postmenopausal Women: A Narrative Review

A growing body of literature has examined the role of physical activity (PA) in modifying the effects of estrogen withdrawal on cardiovascular health in postmenopausal women, but the impact of PA on androgens is less clear. Changes in androgen concentrations following regular PA may improve cardiovascular health. This narrative review summarizes the literature assessing the impact of PA interventions on androgens in postmenopausal women. The association between changes in androgen concentrations and cardiovascular health following PA programs is also examined. Randomized controlled trials were included if they (i) implemented a PA program of any type and duration in postmenopausal women and (ii) measured changes in androgen concentrations. Following PA interventions, no changes in androstenedione, conflicting changes in dehydroepiandrosterone/dehydroepiandrosterone-sulfate, and increases in sex hormone-binding globulin concentrations were found. Total testosterone decreased following aerobic PA but increased after resistance training. Most aerobic PA interventions led to reductions in free testosterone. A combination of caloric restriction and/or fat loss enhanced the influence of PA on most androgens. Evidence exploring the relationship between changes in androgens and cardiovascular health indicators was scarce and inconsistent. PA has shown promise in modifying the concentrations of some androgens (free and total testosterone, sex hormone-binding globulin), and remains a well-known beneficial adjuvant option for postmenopausal women to manage their cardiovascular health. Fat loss influences the effect of PA on androgens, but the synergistic role of PA and androgens on cardiovascular health merits further examination. Many research gaps remain regarding the relationship between PA, androgens, and cardiovascular disease in postmenopausal women.

Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences

Background

The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs).

Objective

To characterize patients’ and providers’ experiences with the quality and sustainability of virtual care for ACSCs.

Design

This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma.

Main measures

Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain.

Key results

Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care.

Conclusions

In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.

OP0030 ASSOCIATION OF TRADITIONAL AND DISEASE-RELATED RISK FACTORS WITH CARDIOVASCULAR EVENTS IN PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background

Patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk for cardiovascular (CV) disease.

Objectives

We aimed to identify traditional CV risk factors and PsD-related risk factors associated with CV events.

Methods

Patients from a longitudinal PsD cohort without a prior history of CV events were included. Detailed information on demographics, comorbidities including traditional cardiovascular risk factors, medications and disease activity is collected according to a standard protocol. The study outcome included any of the following CV events occurring within the first 10 years of patients’ initial clinic visit: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. A total of 10 traditional CV risk factors and 15 PsD-related risk factors were assessed. The association of each risk factor with incident CVEs were analyzed separately using Cox proportional hazards regression models with time-dependent covariates, adjusted for age and sex.

Results

A total of 1,376 patients with PsD, followed between 1978 and 2020, were analyzed (mean age 48.3 ± 12.9 years, 46.8% female). During the follow-up period, 102 (7.4%) patients developed incident CV events. In Cox regression models adjusted for age and sex, age (Hazard Ratio (HR) 1.08, 95% Confidence Interval (CI) 1.06, 1.10), diabetes (HR 1.88, 95% CI 1.17, 3.02), systolic blood pressure (HR 1.02, 95% CI 1.01, 1.03), body mass index (BMI) (HR 1.04, 95% CI 1.01, 1.08), triglycerides (HR 1.24, 95% CI 1.07, 1.43), treatment for hypertension (HR 1.70, 95% CI 1.13, 2.56), and use of lipid-lowering medications (HR 1.70, 95% CI 1.13, 2.56) were among the traditional CV risk factors associated with increased CV risk. Among the PsD-related risk factors, psoriasis area and severity index (PASI) (HR 1.05, 95% CI 1.02, 1.08), erythrocyte sedimentation rate (ESR) (HR 1.02, 95% CI 1.01, 1.02), number of tender joints (HR 1.03, 95% CI 1.01, 1.05), number of swollen joints (HR 1.06, 95% CI 1.01, 1.12), health assessment questionnaire (HAQ) score (HR 1.63, 95% CI 1.23, 2.17), and daily use of non-steroidal anti-inflammatory drugs (NSAIDs) (HR 1.72, 95% CI 1.16, 2.55) were associated with increased CV risk. Use of biologic medications (HR 0.63, 95% CI 0.40, 1.00) was not found to be significantly protective against CV events.

Conclusion

In patients with PsD, we identified six PsD-related risk factors that were significantly associated with incident CV events. These risk factors may be useful for the development of a PsD-specific CV risk prediction score that uses routine clinical assessments in combination with PsD-related biomarkers.

References

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Acknowledgements

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, and Arthritis Society (TGP-19-0446). Lihi Eder is supported by a Young Investigator Award from the Arthritis Society (YIA-16-394) and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The Psoriatic Disease Program has been supported by a grant from the Krembil Foundation.

Disclosure of Interests

None declared.

Association of Cardiac Biomarkers With Cardiovascular Outcomes in Patients With Psoriatic Arthritis and Psoriasis: A Longitudinal Cohort Study

Objective

In patients with psoriatic disease (PsD), we determined whether cardiac troponin I (cTnI) and N‐terminal pro–brain natriuretic peptide (NT‐proBNP) were associated with carotid plaque burden and the development of cardiovascular events independent of the Framingham Risk Score (FRS).

Methods

Among 1,000 patients with PsD, carotid total plaque area (TPA) was measured in 358 participants at baseline. Cardiac troponin I and NT‐proBNP were measured using automated clinical assays. The association between cardiac biomarkers and carotid atherosclerosis was assessed by multivariable regression after adjusting for cardiovascular risk factors. Improvement in the prediction of cardiovascular events beyond the FRS was tested using measures of risk discrimination and reclassification.

Results

In univariate analyses, cTnI (β coefficient 0.52 [95% confidence interval (95% CI) 0.3, 0.74], P < 0.001) and NT‐proBNP (β coefficient 0.24 [95% CI 0.1, 0.39], P < 0.001) were associated with TPA. After adjusting for cardiovascular risk factors, the association remained statistically significant for cTnI (adjusted β coefficient 0.21 [95% CI 0, 0.41], P = 0.047) but not for NT‐proBNP (P = 0.21). Among the 1,000 patients with PsD assessed for cardiovascular risk prediction, 64 patients had incident cardiovascular events. When comparing a base model (with the FRS alone) to expanded models (with the FRS plus cardiac biomarkers), there was no improvement in predictive performance.

Conclusion

In patients with PsD, cTnI may reflect the burden of atherosclerosis, independent of traditional cardiovascular risk factors. Cardiac troponin I and NT‐proBNP are associated with incident cardiovascular events independent of the FRS, but further study of their role in cardiovascular risk stratification is warranted.

“Her Heart Matters”—Making Visible the Cardiac Pain Experiences of Women with Physical Disabilities and Heart Disease: A Qualitative Study

Background

Women with physical disabilities are faced with challenges in many aspects of life—education, work, income, relationships, as well as their general health. These women are at a greater risk of developing heart disease. This study aimed to explore the cardiac pain experiences of women with physical disabilities and heart disease within a Canadian healthcare context.

Methods

In this qualitative study, 8 women with physical disabilities and heart disease from across Canada were interviewed. They were asked about their pre-, peri-, and post-diagnostic experiences in the Canadian healthcare system. Transcripts of the interviews were analyzed using a hermeneutic phenomenological approach inspired by Ricoeur.

Results

Two main themes were uncovered in the analysis of the transcripts, as follows: (i) the diagnostic journey; and (ii) life with cardiac symptoms and a disability. The women indicated that they had experienced difficulties in utilizing the Canadian healthcare system prior to receiving a cardiac diagnosis, including long waitlists, expensive and unreliable transport, issues with accessibility, and dealing with providers’ attitudinal barriers regarding disability. Receiving a diagnosis was challenging due to poor relationships with healthcare providers; however, having a same-sex provider seemed essential to receiving adequate care. Self-managing a disability and heart disease had significant physical and psychological impact, which was lightened by financial and social supports, modified lifestyle choices, and self-advocacy.

Conclusions

Women with physical disabilities are often forgotten in discussions encompassing equity and inclusion. The participants’ experiences offer insight into what changes are needed within the Canadian healthcare system in order to improve outcomes for these women.

POS1068 Cardiac biomarkers are associated with the development of cardiovascular events in patients with psoriatic arthritis and psoriasis

Background:

N-terminal pro-brain-type natriuretic peptide (NT-proBNP) and troponin I (TnI) are established cardiac biomarkers that predict cardiovascular events (CVEs) in the general population. While patients with psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), have an increased risk of developing CVEs, the use of these cardiac biomarkers to predict CV risk has not been investigated in this population.

Objectives:

We aimed to evaluate the association between these cardiac biomarkers and incident CVEs, and assess their predictive value beyond the Framingham Risk Score (FRS).

Methods:

A longitudinal cohort study was conducted in patients with PsD without prior history of CVEs. NT-proBNP and TnI concentrations were measured using automated clinical assays in the first available serum sample. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, transient ischemic attack, stroke, revascularization and CV death. Associations with incident CVEs were analyzed separately for each biomarker using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for the FRS. The added value of cardiac biomarkers to improve predictive performance beyond the FRS was assessed using the area under the receiver operator characteristic curve (AUC), net reclassification index (NRI) and integrated discrimination index (IDI).

Results:

A total of 1000 patients with PsD were assessed between 2002 and 2019 (mean age 49 ± 12.8 years, 44.6% female) (Table 1). During a mean follow-up of 7.1 years, 64 patients developed incident CVEs. Both TnI (Hazard Ratio (HR) 3.02, 95% Confidence Interval (CI) 1.12, 8.16) and NT-proBNP (HR 2.02; 95% CI 1.28, 3.18) predicted CVEs independently of the FRS (Figure 1). The association was stronger in males than females. Including all cardiac biomarkers and the FRS in a single model, NT-proBNP retained statistical significance (HR 1.91, 95% CI 1.23, 2.97), while TnI did not (HR 2.60, 95% CI 0.98, 6.87). When comparing the predictive performance of the base model (FRS alone, AUC 75.4) to the expanded models, there was no significant improvement in any of the predictive indices with the addition of TnI (AUC 73.5, p = 0.21; NRI 0.08, p = 0.67; IDI 0.005, p = 0.37), NT-proBNP (AUC 71.0, p = 0.35; NRI 0.20, p = 0.06; IDI 0.017, p = 0.10), or both TnI and NT-proBNP (AUC 70.0, p = 0.23; NRI 0.27, p = 0.05; IDI 0.021, p =0.05).

Conclusion:

In patients with PsD, elevated NT-proBNP and TnI predict incident CVEs independent of the FRS. We did not observe a significant improvement in the performance of the predictive model when combining these cardiac biomarkers with the FRS.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

Table 1.

Baseline characteristics of the study population (n=1000)

VariableMean ± SD / Frequency (%)PsA, no. (%)648 (64.8)PsC, no. (%)352 (35.2)Age (years)49 ± 12.8Male sex, no. (%)554 (55.4)Disease duration (years)20.2 ± 14.1Ethnicity, Caucasian (%)834 (83.4)Current smoker (%)164 (16.4)FRS (%)8.2 ± 8.6Diabetes77 (7.7)Hypertension274 (27.4)BMI (kg/m2)28.7 ± 5.9PASI4.1 ± 6.3Use of lipid-lowering medications (%)100 (10)Current use of DMARDs362 (36.2)Current use of Biologics214 (21.4)Current use of NSAIDs (daily use)265 (26.5)

1 Applicable only to patients with PsA CVE, cardiovascular events; DMARD, disease-modifying antirheumatic drug; FRS, Framingham Risk Score; NSAID, non-steroidal anti-inflammatory drug; PASI, Psoriasis Area Severity Index; PsA, psoriatic arthritis; PsC, psoriasis without arthritis

Figure 1.

Hazard ratios of cardiac biomarker measures for incident cardiovascular events (n = 1000, 64 events). Error bars denote 95% confidence intervals. CI indicates confidence interval; CVEs, cardiovascular events; FRS, Framingham Risk Score; NT-proBNP, N-terminal pro-brain-type natriuretic peptide; TnI, troponin I.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared.

OP0221 TARGETED METABOLOMIC PROFILING AND PREDICTION OF CARDIOVASCULAR EVENTS: A PROSPECTIVE STUDY OF PATIENTS WITH PSORIATIC ARTHRITIS AND PSORIASIS

Background:

Psoriatic arthritis and psoriasis, collectively termed psoriatic disease (PsD), are associated with increased cardiovascular (CV) risk. Metabolites comprise biomarkers that may add predictive value over traditional CV risk factors.

Objectives:

We aimed to identify metabolites associated with CV events (CVEs) and to determine whether they could improve CV risk prediction beyond traditional CV risk factors.

Methods:

Patients from a longitudinal PsD cohort without a prior history of CVEs were included. In the first available serum sample, a targeted nuclear magnetic resonance (NMR) metabolomics platform was used to quantify 64 metabolite measures comprised of lipoprotein subclasses, fatty acids, glycolysis precursors, ketone bodies and amino acids. The study outcome included any of the following CVEs occurring within the first 10 years of biomarker assessment: angina, myocardial infarction, congestive heart failure, transient ischemic attack, cerebrovascular accident, revascularization procedures and CV death. The association of each metabolite with incident CVEs were analyzed separately using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for traditional CV risk factors. Variable selection was performed using penalization with boosting after adjusting for age and sex. The added predictive value of the selected metabolites to improve risk prediction beyond traditional CV risk factors was assessed using the area under the receiver operator characteristic curve (AUC).

Results:

A total of 977 patients with PsD, followed between 2002 and 2019, were analyzed (mean age 49.1 ± 12.6 years, 45.1% female). During a mean follow-up of 7.1 years, 70 (7.2%) patients developed incident CVEs. In Cox regression models adjusted for CV risk factors, alanine, tyrosine, total high-density lipoprotein (HDL) cholesterol, medium and large HDL particles, and the degree of unsaturation of fatty acids were significantly associated with decreased CV risk. Glycoprotein acetyls, apolipoprotein B, remnant cholesterol, very low-density lipoprotein (VLDL) cholesterol, and very small VLDL particles were associated with an increased CV risk. In proportional sub-distribution hazards regression models adjusted for age and sex, 13 metabolites were selected (Table 1). The age- and sex-adjusted expanded model (base model + 13 metabolites) significantly improved prediction of CVEs beyond the base model (only age and sex) with an AUC of 79.9 vs. 72.6, respectively (p=0.019) (Figure 1).

Table 1.

Regression coefficients of the selected metabolites in a model adjusted for age and sex.

CategoryMetaboliteModel adjusted for Age and SexAmino AcidsAlanine-0.1179Glycine-0.0339Tyrosine-0.1010Fatty acid ratios, relative to total fatty acidsDocosahexaenoic acid-0.0862Unsaturation degree, double bonds per fatty acid-0.1265Fluid BalanceAlbumin+0.0685GlyceridesTriglycerides in IDL cholesterol+0.1546Glycolysis precursorsGlucose+0.1391InflammationGlycoprotein acetyls+0.1478Ketone bodiesAcetoacetate+0.0464Lipoprotein subclassesHDL3 Cholesterol-0.0211Medium HDL-0.0296Large HDL-0.0309Figure 1.

Predictive performance of a model with age and sex alone is compared to a model with age and sex plus selected metabolites.

Conclusion:

Using NMR metabolomics profiling, we identified a variety of metabolites associated with a lower and higher risk of developing CVEs in patients with PsD. Further study of their underlying association with CVEs is needed to clarify the clinical utility of these biomarkers to guide CV risk assessment in this population.

References:

[1]Eder L, Wu Y, Chandran V, et al. Incidence and predictors for cardiovascular events in patients with psoriatic arthritis. Ann Rheum Dis 2016;75(9):1680-6.

[2]Soininen P, Kangas AJ, Wurtz P, et al. Quantitative serum nuclear magnetic resonance metabolomics in cardiovascular epidemiology and genetics. Circ Cardiovasc Genet 2015;8(1):192-206.

Acknowledgements:

Keith Colaco is supported by the Enid Walker Estate, Women’s College Research Institute, Arthritis Society (TGP-19-0446), National Psoriasis Foundation (Early Career Grant) and the Edward Dunlop Foundation. Lihi Eder is supported by a Young Investigator Award from the Arthritis Society and an Early Researcher Award from the Ontario Ministry of Science and Innovation. The study was supported in part by a discovery grant from the National Psoriasis Foundation and an operating grant from the Arthritis Society (YIO-16-394).

Disclosure of Interests:

None declared

Targeted metabolomic profiling and prediction of cardiovascular events: a prospective study of patients with psoriatic arthritis and psoriasis

OBJECTIVE

In patients with psoriatic disease (PsD), we sought serum metabolites associated with cardiovascular (CV) events and investigated whether they could improve CV risk prediction beyond traditional risk factors and the Framingham Risk Score (FRS).

METHODS

Nuclear magnetic resonance metabolomics identified biomarkers for incident CV events in patients with PsD. The association of each metabolite with incident CV events was analysed using Cox proportional hazards regression models first adjusted for age and sex, and subsequently for traditional CV risk factors. Variable selection was performed using penalisation with boosting after adjusting for age and sex, and the FRS.

RESULTS

Among 977 patients with PsD, 70 patients had incident CV events. In Cox regression models adjusted for CV risk factors, alanine, tyrosine, degree of unsaturation of fatty acids and high-density lipoprotein particles were associated with decreased CV risk. Glycoprotein acetyls, apolipoprotein B and cholesterol remnants were associated with increased CV risk. The age-adjusted and sex-adjusted expanded model with 13 metabolites significantly improved prediction of CV events beyond the model with age and sex alone, with an area under the receiver operator characteristic curve (AUC) of 79.9 versus 72.6, respectively (p=0.02). Compared with the FRS alone (AUC=73.9), the FRS-adjusted expanded model with 11 metabolites (AUC=75.0, p=0.72) did not improve CV risk discrimination.

CONCLUSIONS

We identify novel metabolites associated with the development of CV events in patients with PsD. Further study of their underlying causal role may clarify important pathways leading to CV events in this population.

Assessment of cardiovascular risk tools as predictors of cardiovascular disease events in systemic lupus erythematosus

BACKGROUND

SLE is an independent risk factor for cardiovascular disease (CVD). This study aimed to determine which among QRISK2, QRISK3, Framingham Risk Score (FRS), modified Framingham Risk Score (mFRS) and SLE Cardiovascular Risk Equation (SLECRE) best predicts CVD.

METHODS

This is a single-centre analysis on 1887 patients with SLE followed prospectively according to a standard protocol. Tools' scores were evaluated against CVD development at/within 10 years for patients with CVD and without CVD. For patients with CVD, the index date for risk score calculation was chosen as close to 10 years prior to CVD event. For patients without CVD, risk scores were calculated as close to 10 years prior to the most recent clinic appointment. Proportions of low-risk (<10%), intermediate-risk (10%-20%) and high-risk (>20%) patients for developing CVD according to each tool were determined, allowing sensitivity, specificity, positive/negative predictive value and concordance (c) statistics analysis.

RESULTS

Among 1887 patients, 232 CVD events occurred. QRISK2 and FRS, and QRISK3 and mFRS, performed similarly. SLECRE classified the highest number of patients as intermediate and high risk. Sensitivities and specificities were 19% and 93% for QRISK2, 22% and 93% for FRS, 46% and 83% for mFRS, 47% and 78% for QRISK3, and 61% and 64% for SLECRE. Tools were similar in negative predictive value, ranging from 89% (QRISK2) to 92% (SLECRE). FRS and mFRS had the greatest c-statistics (0.73), while QRISK3 and SLECRE had the lowest (0. 67).

CONCLUSION

mFRS was superior to FRS and was not outperformed by the QRISK tools. SLECRE had the highest sensitivity but the lowest specificity. mFRS is an SLE-adjusted practical tool with a simple, intuitive scoring system reasonably appropriate for ambulatory settings, with more research needed to develop more accurate CVD risk prediction tools in this population.

Incidence of and Risk Factors for Heart Failure in Patients with Psoriatic Disease - A Cohort Study

OBJECTIVES

To assess the incidence and risk factors for heart failure (HF) in patients with psoriatic disease (PsD) and describe their electrocardiographic and echocardiographic findings.

METHODS

A cohort analysis was conducted involving patients with PsD followed prospectively from 1978 to 2018. Participants were assessed according to a standard protocol every 6 to 12-months. The primary outcome was the time to first event of HF, further classified into ischemic and non-ischemic HF (secondary outcomes). The association between cardiovascular risk factors, measures of disease activity and HF events was assessed using Cox proportional hazards regression. Electrocardiographic and echocardiographic findings associated with HF events were described.

RESULTS

A total of 1994 patients with PsD were analyzed with 64 incident HF events (38 ischemic, 26 non-ischemic). The incidence rate of first HF event was 2.85 per 1000 patient years. In all events, most common electrocardiographic findings were atrial fibrillation (22%) and bundle branch blocks (29%). Echocardiogram revealed 37% reduced ejection fraction and 63% preserved ejection fraction. In multivariable analysis, independent risk factors for all HF events were ischemic heart disease, adjusted mean (AM)-tender joint count, AM-swollen joint count, AM-erythrocyte sedimentation rate, AM-C-reactive protein, and physical function (by health assessment questionnaire) (all p<0.05). Minimal disease activity state was protective for all HF (p<0.05).

CONCLUSIONS

Increased risk of HF is associated with a combination of known cardiovascular risk factors and measures of disease activity, particularly in non-ischemic HF. The effect of inflammation on HF may be partially independent of atherosclerotic disease.

SAT0586 PREVALENCE AND RISK FACTORS FOR CARDIO-METABOLIC ABNORMALITIES IN PATIENTS WITH INFLAMMATORY ARTHRITIS ATTENDING CARDIO-RHEUMATOLOGY PRIMARY PREVENTION CLINICS

Background:

Cardio-metabolic abnormalities are common in patients with inflammatory arthritis (IA) but tend to be under-recognized and under-treated.

Objectives:

We aimed to compare the prevalence and risk factors for cardio-metabolic abnormalities between patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS).

Methods:

Consecutive patients enrolled in the University of Toronto Cardio-Rheumatology Network from July 2017 to August 2019 were analyzed. This is a primary prevention program that uses structured clinical, laboratory and multimodal imaging to diagnose and treat cardiovascular disease (CVD). Patients with a rheumatologist-confirmed diagnosis of RA, PsA or AS with no known CVD were evaluated. Information about IA diagnosis, medications and comorbidities was recorded. Each patient was evaluated by a cardiologist focusing on CVD risk assessment. We evaluated the prevalence of previously recorded and newly recognized cardio-metabolic risk factors including hypertension, dyslipidemia, obesity and diabetes. The prevalence of these abnormalities was compared between IA diagnoses. Regression models were used to assess the association between diagnosis and cardio-metabolic abnormalities after adjusting for demographics, smoking, BMI, measures of disease activity and medications.

Results:

A total of 358 patients (201 RA, 124 PsA, 33 AS) were assessed (mean age 59±10.5 years, 68.7% female). Hypertension was reported in 33%, dyslipidemia in 26.8%, diabetes mellitus in 8.9% and overweight/obesity in 69.7% (Figure 1). Newly detected elevations in lipids were frequent for triglycerides (9.3%,), non-HDL-cholesterol (6%,) and LDL-cholesterol (2.7%). Elevated HbA1c occurred in 1.4% and newly diagnosed hypertension occurred in 9.8%. A total of 32.8% patients required a change or initiation of medications for their cardio-metabolic abnormalities (21.7% lipid-lowering therapy, 14.6% aspirin, 11.1% anti-hypertension therapy). Patients with PsA had the highest prevalence of cardio-metabolic abnormalities including dyslipidemia, obesity and hypertension. Having hypertension (prior or new diagnosis), elevated levels of triglycerides, non-HDL cholesterol, total cholesterol and BMI were associated with PsA vs. RA after adjusting for potential confounders (all p<0.05) (Figure 2). No significant association was found between cardio-metabolic abnormalities and AS vs. PsA or RA.

Conclusion:

Dedicated cardio-rheumatology clinics have improved CVD screening and management in an IA population. The burden of cardio-metabolic abnormalities is elevated in PsA and suggests that tailored strategies to reduce adverse CVD events are particularly needed in this subgroup.

Disclosure of Interests:

Lihi Eder Grant/research support from: Abbvie, Lily, Janssen, Amgen, Novartis, Consultant of: Janssen, Speakers bureau: Abbvie, Lily, Janssen, Amgen, Novartis, Shadi Akhtari: None declared, Paula Harvey: None declared, Kuriya Bindee Grant/research support from: Abbvie, Pfizer, Sanofi, BMS, Consultant of: Abbvie, Eli Lily, Pfizer

Development and usability testing of HEARTPA♀N: protocol for a mixed methods strategy to develop an integrated smartphone and web-based intervention for women with cardiac pain

INTRODUCTION

More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.

METHODS AND ANALYSIS

This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.

TRIAL REGISTRATION NUMBER

NCT03800082.

Value of Carotid Ultrasound in Cardiovascular Risk Stratification in Patients With Psoriatic Disease

OBJECTIVE

This study aimed to assess whether subclinical atherosclerosis, as evaluated by carotid ultrasound, could predict incident cardiovascular events (CVEs) in patients with psoriatic disease (PsD) and determine whether incorporation of imaging data could improve CV risk prediction by the Framingham Risk Score (FRS).

METHODS

In this cohort analysis, patients with PsD underwent ultrasound assessment of the carotid arteries at baseline. The extent of atherosclerosis was assessed using carotid intima-media thickness (CIMT) and total plaque area (TPA). Incident CVEs (new or recurrent) that occurred following the ultrasound assessment were identified. The association between measures of carotid atherosclerosis and the risk of developing an incident CVE was evaluated using Cox proportional hazards models, with adjustment for the FRS.

RESULTS

In total, 559 patients with PsD were assessed, of whom 23 had incident CVEs ascertained. The calculated rate of developing a first CVE during the study period was 1.11 events per 100 patient-years (95% confidence interval [95% CI] 0.74-1.67). When analyzed separately in Cox proportional hazards models that were controlled for the FRS, the TPA (hazard ratio [HR] 3.74, 95% CI 1.55-8.85; P = 0.003), mean CIMT (HR 1.21, 95% CI 1.03-1.42; P = 0.02), maximal CIMT (HR 1.11, 95% CI 1.01-1.22; P = 0.03), and high TPA category (HR 3.25, 95% CI 1.18-8.95; P = 0.02) were each predictive of incident CVEs in patients with PsD.

CONCLUSION

The burden of carotid atherosclerosis is associated with an increased risk of developing future CVEs. Combining vascular imaging data with information on traditional CV risk factors could improve the accuracy of CV risk stratification in patients with PsD.

Predictive Utility of Cardiovascular Risk Prediction Algorithms in Inflammatory Rheumatic Diseases: A Systematic Review

Objective.

We performed a systematic review of the literature to describe current knowledge of cardiovascular (CV) risk prediction algorithms in rheumatic diseases.

Methods.

A systematic search of MEDLINE, EMBASE, and Cochrane Central databases was performed. The search was restricted to original publications in English, had to include clinical CV events as study outcomes, assess the predictive properties of at least 1 CV risk prediction algorithm, and include patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), or psoriasis. By design, only cohort studies that followed participants for CV events were selected.

Results.

Eleven of 146 identified manuscripts were included. Studies evaluated the predictive performance of the Framingham Risk Score, QRISK2, Systematic Coronary Risk Evaluation (SCORE), Reynolds Risk Score, American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE), Expanded Cardiovascular Risk Prediction Score for Rheumatoid Arthritis (ERS-RA), and the Italian Progetto CUORE score. Approaches to improve predictive performance of general risk algorithms in patients with RA included the use of multipliers, biomarkers, disease-specific variables, or a combination of these to modify or develop an algorithm. In both SLE and PsA patients, multipliers were applied to general risk algorithms. In studies of RA and SLE patients, efforts to include nontraditional risk factors, disease-related variables, multipliers, and biomarkers largely failed to substantially improve risk estimates.

Conclusion.

Our study confirmed that general risk algorithms mostly underestimate and at times overestimate CV risk in rheumatic patients. We did not find studies that evaluated models for psoriasis or AS, which further demonstrates a need for research in these populations.

Antimalarial-induced Cardiomyopathy in Systemic Lupus Erythematosus: As Rare as Considered?

OBJECTIVE

Antimalarials (AM) are recommended for all systemic lupus erythematosus (SLE) patients without specific contraindications. Their main adverse effect is retinal damage; however, heart disease has been described in isolated cases. The aim of our study is to describe 8 patients with AM-induced cardiomyopathy (AMIC) in a defined SLE cohort.

METHODS

Patients attending the Toronto Lupus Clinic and diagnosed with definite (based on endomyocardial biopsy; EMB) and possible AMIC were included [based on cardiac magnetic resonance imaging (cMRI) and other investigations].

RESULTS

Eight female patients (median age 62.5 yrs, disease duration 35 yrs, AM use duration 22 yrs) were diagnosed with AMIC in the past 2 years. Diagnosis was based on EMB in 3 (extensive cardiomyocyte vacuolation, intracytoplasmic myelinoid, and curvilinear bodies). In 4 patients, cMRI was highly suggestive of AMIC (ventricular hypertrophy and/or atrial enlargement and late gadolinium enhancement in a nonvascular pattern). Another patient was diagnosed with complete atrioventricular block, left ventricular and septal hypertrophy, along with concomitant ocular toxicity. All patients had abnormal cardiac troponin I (cTnI) and brain natriuretic peptide (BNP), whereas 7/8 also had chronically elevated creatine phosphokinase. During followup, 1 patient died from refractory heart failure. In the remaining patients, hypertrophy regression and a steady decrease of heart biomarkers were observed after AM cessation.

CONCLUSION

Once considered extremely rare, AMIC seems to be underrecognized, probably because of the false attribution of heart failure or hypertrophy to other causes. Certain biomarkers (cTnI, BNP) and imaging findings may lead to early diagnosis and enhance survival.

Self-Management of Cardiac Pain in Women: A Meta-Summary of the Qualitative Literature

Symptom recognition and self-management is instrumental in reducing the number of deaths related to coronary artery disease (CAD) in women. The purpose of this study was to synthesize qualitative research evidence on the self-management of cardiac pain and associated symptoms in women. Seven databases were systematically searched, and the concepts of the Individual and Family Self-Management Theory were used as the framework for data extraction and analysis. Search strategies yielded 22,402 citations, from which 35 qualitative studies were included in a final meta-summary, comprising data from 769 participants, including 437 (57%) women. The available literature focused cardiac pain self-management from a binary sex and gender perspective. Ethnicity was indicated in 19 (54%) studies. Results support individualized intervention strategies that promote goal setting and action planning, management of physical and emotional responses, and social facilitation provided through social support.

Abnormal Cardiac Biomarkers in Patients with Systemic Lupus Erythematosus and No Prior Heart Disease: A Consequence of Antimalarials?

OBJECTIVE

Cardiac involvement in systemic lupus erythematosus (SLE) is often undiagnosed in its early phases. Specific heart biomarkers may identify patients at risk. We sought to investigate the prevalence and associated factors for such biomarkers in SLE.

METHODS

Brain natriuretic peptide (BNP) and cardiac troponin I (cTnI) were measured simultaneously in 151 consecutive patients with no history of heart disease or pulmonary arterial hypertension (PAH). None had electrocardiographic abnormalities suggestive of acute coronary syndrome. Cross-sectional comparisons and logistic regression analyses were performed. Patients with abnormal biomarkers were investigated to delineate the specific cause.

RESULTS

Sixteen patients (16/151, 10.6%) had elevated BNP, and 9 of them also had abnormal cTnI. Compared to subjects with normal biomarkers, they were older, had longer disease and antimalarial (AM) use duration, and more frequently persistent creatine phosphokinase (CPK) elevation. Multivariable regression analysis showed prolonged AM treatment (> 5.6 yrs) and persistent CPK elevation to be important predictors for elevated cardiac biomarkers. Six patients were diagnosed with definite (based on endomyocardial biopsy, n = 2) or possible (based on cardiac magnetic resonance after exclusion of other causes) AM-induced cardiomyopathy (AMIC); all had both BNP and cTnI elevated. Alternative causes were identified in 5, while no definitive diagnosis could be made in the remaining patients.

CONCLUSION

About 10% of patients with SLE had elevated myocardial biomarkers, in the absence of prior cardiac disease or PAH. One-third of them were diagnosed with AMIC. Prolonged AM therapy and persistent CPK elevation conferred an increased risk for abnormal BNP and cTnI, which might predict AMIC.

Electrocardiogram abnormalities related to anti-malarials in systemic lupus erythematosus

OBJECTIVES

Cardiotoxicity with potential conduction/structural abnormalities on electrocardiogram (ECG) have been reported with anti-malarial (AM). We aimed to study whether cumulative AM is associated with ECG abnormalities.

METHODS

A standard resting supine ECG was performed on consecutive patients attending the Lupus Clinic since 2012. ECG abnormalities were grouped into structural [left ventricular hypertrophy or atrial enlargement] and conduction abnormalities [prolonged corrected QT interval (QTc), short PR interval, left bundle branch block (LBBB), right bundle branch block (RBBB) and atrioventricular block (AVB), bradycardia, tachycardia, premature atrial complex, ectopic atrial rhythm, atrial fibrillation, premature ventricular complex and ventricular bigeminy]. Associations between cumulative AM and ECG abnormalities (structural or conduction) were assessed using logistic regression analysis (after adjusting for baseline patient characteristics) and in a nested case-control study (1:3).

RESULTS

Of 453 patients treated with AM, the median cumulative AM was 1207 grams at ECG. Conduction abnormalities were more prevalent than structural abnormalities, 71 (15.7%) vs. 58 (12.8%). AM cumulative dose did not show a statistical significant association with ECG structural abnormalities, (OR 1.82, p=0.07) while it was protective for conduction ECG abnormalities (OR 0.42, p=0.006). The nested case-control analysis also found that AM cumulative dose is protective against conduction ECG abnormalities (OR 0.36, p=0.0007). SLE duration was a risk factor for both structural and conduction ECG abnormalities.

CONCLUSIONS

This study suggests an association between cumulative AM dose above the median (1207 g) and structural ECG abnormalities. More importantly, cumulative AM decreases the odds of ECG conduction abnormalities.

Severe brady-arrhythmias in systemic lupus erythematosus: prevalence, etiology and associated factors

Background

Severe brady-arrhythmias, requiring a permanent pacemaker (PPM), have been sparsely reported in systemic lupus erythematosus (SLE). The aim of this study was to describe the characteristics of such arrhythmias in a defined lupus cohort.

Patients and methods

The database of the Toronto Lupus Clinic ( n = 1366) was searched for patients who received a PPM. Demographic, clinical, immunological and therapeutic variables along with electrocardiographic (ECG) and echocardiographic findings (based on the last available test prior to PPM) were analyzed. Patients with a PPM (cases) were compared with age-, sex- and disease duration-matched patients without a PPM (controls). Analysis was performed with SAS 9.0; p < 0.05 was considered significant.

Results

Eighteen patients were identified, 13 (0.95%) with complete atrioventricular block and 5 (0.37%) with sick sinus syndrome. Disease duration at PPM implantation was 22 ± 12 years. Compared to controls, cases had more frequently coronary artery disease, hypertension, dyslipidemia and longer antimalarial (AM) treatment duration. The prevalence of first-degree atrioventricular block, right bundle branch block, left anterior fascicular block and septal hypertrophy was also higher. AM treatment was significantly associated with brady-arrhythmias (OR = 1.128, 95% CI = 1.003–1.267, p = 0.044). Nine patients had prior heart disease and one received a PPM two years after renal transplantation. Eight patients did not have any potential risk factors; prolonged AM therapy (mean 22 years) might have been the cause.

Conclusions

Apart from known causes, prolonged AM treatment may be associated with severe brady-arrhythmias in SLE. Certain ECG and echocardiographic characteristics may represent indicators of an ongoing damage in the conduction system.

General Anesthesia with Endotracheal Intubation for Cryotherapy for Retinopathy of Prematurity

We present a technique for treating retinopathy of prematurity (ROP) with cryotherapy under general anesthesia, administered and monitored by a neonatologist, with endotracheal intubation in the neonatal intensive care unit that avoids the serious systemic complications associated with the administration of local anesthetics. Although no significant complications arose in this series, having the intubated infant monitored by trained neonatology staff allows appropriate management should complications arise. We have used this technique to treat 20 eyes with threshold ROP. The mean time to extubation was 40.2 hours. The systemic status and discharge from the neonatal intensive care unit were not influenced by the general anesthesia. This technique allows quick and accurate application of the cryotherapy in a stable and controlled setting. We recommend that physicians consider cryotherapy under general anesthesia with endotracheal intubation for infants with ROP. This technique allows ROP to be treated adequately with minimal risk to the infant.

Self-Management Interventions for Women With Cardiac Pain: A Systematic Review and Meta-analysis

BACKGROUND

Cardiac pain is considered the primary indicator of coronary artery disease (CAD). Existing reviews lack appropriate numbers of women or sex-based subgroup analyses, or both; thus, the benefits of self-management (women with cardiac pain actively participating in their own care and treatment) remain uncertain.

METHODS

Using methods described by the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, 7 databases were systematically searched to examine and synthesize the evidence on self-management interventions for women with cardiac pain and cardiac pain equivalents, such as fatigue, dyspnea, and exhaustion.

RESULTS

Our search yielded 22,402 article titles and abstracts. Of these, 57 randomized controlled trials were included in a final narrative synthesis, comprising data from 13,047 participants, including 5299 (41%) women. Self-management interventions targeting cardiac pain in women compared with a control population reduced (1) cardiac pain frequency and cardiac pain proportion (obstructive and nonobstructive CAD), (2) fatigue at 12 months, and (3) dyspnea at 2 months. There was no evidence of group differences in postprocedural (percutaneous coronary intervention or cardiac surgery) pain. Results indicated that self-management interventions for cardiac pain were more effective if they included a greater proportion of women (standardized mean difference [SMD], -0.01; standard error, 0.003; P = 0.02), goal setting (SMD, -0.26; 95% confidence interval [CI], -0.49 to -0.03), and collaboration/support from health care providers (SMD, -0.57; 95% CI, -1.00 to -0.14).

CONCLUSIONS

The results of this review suggest that self-management interventions reduce cardiac pain and cardiac pain equivalents.

Gaps in Diagnosis and Treatment of Cardiovascular Risk Factors in Patients with Psoriatic Disease: An International Multicenter Study

OBJECTIVE

We aimed to estimate the proportion of underdiagnosis and undertreatment of cardiovascular risk factors (CVRF) in an international multicenter cohort of patients with psoriasis and psoriatic arthritis (PsA).

METHODS

A cross-sectional analysis was conducted of patients with psoriatic disease from the International Psoriasis and Arthritis Research Team cohort. The presence of modifiable CVRF [diabetes, hypertension (HTN), dyslipidemia, smoking, elevated body mass index, and central obesity] and the use of appropriate therapies for HTN and dyslipidemia were determined. The 10-year CV risk was calculated according to the Framingham Risk Score. Physician adherence with guidelines for the treatment of dyslipidemia and HTN was assessed. Regression analysis was used to assess predictors of undertreatment of HTN and dyslipidemia.

RESULTS

A total of 2254 patients (58.9% PsA, 41.1% psoriasis) from 8 centers in Canada, the United States, and Israel were included. Their mean age was 52 ± 13.8 years and 53% were men. Of the patients, 87.6% had at least 1 modifiable CVRF, 45.1% had HTN, 49.4% dyslipidemia, 13.3% diabetes, 75.3% were overweight or obese, 54.3% central obesity, and 17.3% were current smokers. We found 59.2% of patients with HTN and 65.6% of patients with dyslipidemia were undertreated. Undertreatment was associated with younger age (≤ 50 yrs), having psoriasis, and male sex.

CONCLUSION

In real-world settings, a large proportion of patients with psoriasis and PsA were underdiagnosed and undertreated for HTN and dyslipidemia. Strategies to improve the management of CVRF in psoriatic patients are warranted.

Self-management of cardiac pain in women: an evidence map

OBJECTIVE

To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping.

DESIGN AND SETTING

Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age.

INTERVENTIONS

Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life.

RESULTS

The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years.

CONCLUSIONS

Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain.

PROSPERO REGISTRATION NUMBER

CRD42016042806.

GAMBLINGLESS: FOR LIFE study protocol: a pragmatic randomised trial of an online cognitive-behavioural programme for disordered gambling

INTRODUCTION

The prevalence of disordered gambling worldwide has been estimated at 2.3%. Only a small minority of disordered gamblers seek specialist face-to-face treatment, and so a need for alternative treatment delivery models that capitalise on advances in communication technology, and use self-directed activity that can complement existing services has been identified. As such, the primary aim of this study is to evaluate an online self-directed cognitive-behavioural programme for disordered gambling (GamblingLess: For Life).

METHODS AND ANALYSIS

The study will be a 2-arm, parallel group, pragmatic randomised trial. Participants will be randomly allocated to a pure self-directed (PSD) or guided self-directed (GSD) intervention. Participants in both groups will be asked to work through the 4 modules of the GamblingLess programme over 8 weeks. Participants in the GSD intervention will also receive weekly emails of guidance and support from a gambling counsellor. A total of 200 participants will be recruited. Participants will be eligible if they reside in Australia, are aged 18 years and over, have access to the internet, have adequate knowledge of the English language, are seeking help for their own gambling problems and are willing to take part in the intervention and associated assessments. Assessments will be conducted at preintervention, and at 2, 3 and 12 months from preintervention. The primary outcome is gambling severity, assessed using the Gambling Symptom Assessment Scale. Secondary outcomes include gambling frequency, gambling expenditure, psychological distress, quality of life and additional help-seeking. Qualitative interviews will also be conducted with a subsample of participants and the Guides (counsellors).

ETHICS AND DISSEMINATION

The study has been approved by the Deakin University Human Research and Eastern Health Human Research Ethics Committees. Findings will be disseminated via report, peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12615000864527; results.

Osteoarthritis-related difficulty walking and risk for diabetes complications

OBJECTIVES

To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA.

DESIGN

A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events.

RESULTS

Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04).

CONCLUSIONS

In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Blood pressure-lowering effects of nifedipine/candesartan combinations in high-risk individuals: subgroup analysis of the DISTINCT randomised trial

The DISTINCT study (reDefining Intervention with Studies Testing Innovative Nifedipine GITS-Candesartan Therapy) investigated the efficacy and safety of nifedipine GITS/candesartan cilexetil combinations vs respective monotherapies and placebo in patients with hypertension. This descriptive sub-analysis examined blood pressure (BP)-lowering effects in high-risk participants, including those with renal impairment (estimated glomerular filtration rate<90 ml min^-1, n=422), type 2 diabetes mellitus (n=202), hypercholesterolaemia (n=206) and cardiovascular (CV) risk factors (n=971), as well as the impact of gender, age and body mass index (BMI). Participants with grade I/II hypertension were randomised to treatment with nifedipine GITS (N) 20, 30, 60 mg and/or candesartan cilexetil (C) 4, 8, 16, 32 mg or placebo for 8 weeks. Mean systolic BP and diastolic BP reductions after treatment in high-risk participants were greater, overall, with N/C combinations vs respective monotherapies or placebo, with indicators of a dose-response effect. Highest rates of BP control (ESH/ESC 2013 guideline criteria) were also achieved with highest doses of N/C combinations in each high-risk subgroup. The benefits of combination therapy vs monotherapy were additionally observed in patient subgroups categorised by gender, age or BMI. All high-risk participants reported fewer vasodilatory adverse events in the pooled N/C combination therapy than the N monotherapy group. In conclusion, consistent with the DISTINCT main study outcomes, high-risk participants showed greater reductions in BP and higher control rates with N/C combinations compared with respective monotherapies and lesser vasodilatory side-effects compared with N monotherapy.

Effects of estradiol on measurements of conduit artery endothelial function after ischemia and reperfusion in premenopausal women

In premenopausal women, ovarian steroids are felt to play a role in the prevention of cardiovascular disease. We aimed to assess whether menstrual cycle variations in estrogen can modify the response to ischemia-reperfusion (IR) injury in humans. In an investigator-blinded crossover study, 10 healthy premenopausal women with regular menstrual cycles were studied. They had flow-mediated dilatation (FMD) measured by ultrasound in the radial artery before and after IR (15 min of brachial artery ischemia, 15 min of reperfusion) during both the early and late follicular phases of the menstrual cycle. The order of these visits was not randomized. IR significantly blunted FMD in the early follicular phase (pre-IR: 7.1% ± 1.0%; post-IR: 3.6% ± 1.0%, P = 0.01) when estradiol levels were low (148.4 ± 19.8 pmol/L). Conversely, FMD was preserved after IR during the late follicular phase (pre-IR: 7.2% ± 0.9%; post-IR: 7.0% ± 0.8%, P = NS, P = 0.03 compared with early follicular) when estradiol levels were high (825.7 ± 85.8 pmol/L, P < 0.001 compared with early follicular). There was a significant inverse relationship between estradiol concentration and IR-induced endothelial dysfunction (i.e., change in FMD after IR) (r = 0.59, r² = 0.36, P < 0.01). These findings demonstrate, for the first time in humans, a clear relationship between the cyclical changes in serum concentrations of estradiol and the endothelium's response to IR.